Abstract

Introduction

The Brazilian National Health System (SUS) is one of the largest and most complex public healthcare systems in the world, providing the Brazilian population with healthcare as a citizenship right. Among its various responsibilities, SUS is tasked with organizing the training of human resources in the healthcare field. The responsibility for formulating policies for management, training, qualification, and regulation of healthcare professions is directed to the Ministry of Health (MS)¹1 Brasil. Constituição da República Federativa do Brasil de 1988. Brasília: Senado Federal; 1988.

2 Brasil. Lei Nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 19 Set 1990. ^-33 Batista SHSS, Jansen B, Assis EQ, Senna MIB, Cury GC. Formação em saúde: reflexões a partir dos Programas Pró-Saúde e PET-Saúde. Interface (Botucatu). 2015; 19 Suppl 1:743-52. doi: 10.1590/1807-57622014.0996.
https://doi.org/10.1590/1807-57622014.09... .

Significant government initiatives have been implemented to reorient professional training and work within SUS. These initiatives include the National Policy for Permanent Health Education (Pneps), the National Program for the Reorientation of Professional Training in Health (Pró-Saúde), the Education through Work Program for Health (Pet-Saúde), the Program for the Valorization of Basic Care Professionals (Provab), the More Doctors Program (PMM), and the Organizational Contract of Public Action for Education and Health (Coapes)⁴4 Negrini LDO. Integração ensino-serviço-comunidade no município de Bragança Paulista - SP a partir do contrato organizativo de ação pública ensino-saúde [dissertação]. São Paulo: Universidade Federal de São Paulo; 2022..

With the establishment of SUS and its democratic principles, healthcare in Brazil underwent significant changes, posing challenges for Higher Education Institutions (HEIs). These challenges particularly concern the training of healthcare professionals and a shift in pedagogical models, which now incorporate health policies and adopt teaching, learning, and assessment methodologies that enable students to become self-directed, ethical, humane, and competent learners⁵5 Gonzalez AD, Almeida MJ. Integralidade da saúde: norteando mudanças na graduação dos novos profissionais. Cienc Saude Colet. 2010; 15(3):757-62. doi: 10.1590/S1413-81232010000300018.
https://doi.org/10.1590/S1413-8123201000... .

Since 2001, the Ministry of Education (Mec) has published successive editions of the National Curricular Guidelines (DCN) for the 14 existing healthcare professional categories at the time. The DCN results from a political, institutional, cultural, and educational process aimed at developing pedagogical projects and curricula for healthcare courses, with a focus on promoting a broad and humanistic education that integrates SUS as a learning environment⁶6 Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499. doi: 10.1590/Interface.190499.
https://doi.org/10.1590/Interface.190499... ^,77 Costa DAS, Silva RF, Lima VV, Ribeiro ECO. Diretrizes curriculares nacionais das profissões da saúde 2001-2004: análise à luz das teorias de desenvolvimento curricular. Interface (Botucatu). 2018; 22(67):1183-95. doi: 10.1590/1807-57622017.0376.
https://doi.org/10.1590/1807-57622017.03... .

According to Zarpelon et al.⁸8 Zarpelon LFB, Terencio ML, Batista NA. Integração ensino-serviço no contexto das escolas médicas brasileiras: revisão integrativa. Cienc Saude Colet. 2018; 23(12):4241-8. doi: 10.1590/1413-812320182312.32132016.
https://doi.org/10.1590/1413-81232018231... , the curriculum design for healthcare education should be guided by the education-service-community integration (ESCI) to facilitate the convergence of teaching and service and eliminate the dichotomy between teaching and healthcare delivery. ESCI represents collective work between healthcare service teams, professors, students, healthcare workers, SUS managers, and social control, which includes service users. This collaboration aims to enhance the quality of education and individual or collective healthcare delivery, as well as the satisfaction of healthcare Workers⁹9 Albuquerque VS, Gomes AP, Rezende CHA, Sampaio MX, Dias OV, Lugarinho RM. A integração ensino-serviço no contexto dos processos de mudança na formação superior dos profissionais da saúde. Rev Bras Educ Med. 2008; 32(3):356-62. doi: 10.1590/S0100-55022008000300010.
https://doi.org/10.1590/S0100-5502200800... .

Through collaborative efforts of the Ministry of Health and Mec, the Interministerial Ordinance n. 1127 was published on August 4, 2015. This document establishes Coapes as part of Pneps, focusing on the participatory development of education within and for SUS. It encourages local dialogues that inform the creation of ESCI, allowing stakeholders to discuss, agree on, and organize practice settings, recognize their responsibilities, and emphasize education, research, extension, Permanent Health Education (EPS), and SUS¹⁰10 Brasil. Ministério da Educação, Ministério da Saúde. Portaria Interministerial nº 1.127, de 04 de agosto de 2015. Institui as diretrizes para a celebração dos Contratos Organizativos de Ação Pública Ensino-Saúde (Coapes), para o fortalecimento da integração entre ensino, serviços e comunidade no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 5 Ago 2015..

It is envisioned that Coapes, through contractual agreements, will facilitate negotiations and decisions among SUS stakeholders (managers, workers, and users) and healthcare education (managers, educators, and students). Coapes aims to promote shared responsibility for education, improving healthcare indicators, and thereby facilitating access to and learning opportunities within SUS, with a focus on professional development. This is particularly relevant in addressing the existing gap between theory and practice in professional healthcare education in Brazil⁸8 Zarpelon LFB, Terencio ML, Batista NA. Integração ensino-serviço no contexto das escolas médicas brasileiras: revisão integrativa. Cienc Saude Colet. 2018; 23(12):4241-8. doi: 10.1590/1413-812320182312.32132016.
https://doi.org/10.1590/1413-81232018231... ^,1111 Mendes KMC, Carnut L, Guerra LDS. Cenários de práticas na Atenção Primária à Saúde no Sistema Único de Saúde e a neoseletividade induzida pelo “Programa Previne Brasil”. J Manag Prim Health Care. 2022; 14:e002. doi: 10.14295/jmphc.v14.1186.
https://doi.org/10.14295/jmphc.v14.1186... ^,1212 Sordi MRL, Mendes GSCV, Cyrino EG, Alexandre FLF, Manoel CM, Lopes CVM. Experiência de construção coletiva de instrumento autoavaliativo a serviço da formação médica referenciada nas Diretrizes Curriculares Nacionais (DCN) pautadas no Programa Mais Médicos. Interface (Botucatu). 2020; 24:e190527. doi: 10.1590/Interface.190527.
https://doi.org/10.1590/Interface.190527... .

Sotero and Freitas¹³13 Sotero RL, Freitas RR. Panorama nacional de cooperação e integração do ensino, serviço e comunidade no âmbito da saúde: uma revisão integrativa da literatura. Health Biosci. 2021; 2(1):31-50. doi: 10.47456/hb.v2i1.32704.
https://doi.org/10.47456/hb.v2i1.32704... conducted a literature review on cooperation agreements following the Coapes ordinance, indicating a limited increase in agreements that define and specify ESCI. Costa⁷7 Costa DAS, Silva RF, Lima VV, Ribeiro ECO. Diretrizes curriculares nacionais das profissões da saúde 2001-2004: análise à luz das teorias de desenvolvimento curricular. Interface (Botucatu). 2018; 22(67):1183-95. doi: 10.1590/1807-57622017.0376.
https://doi.org/10.1590/1807-57622017.03... , in a study of Coapes in two different healthcare regions in Rio Grande do Norte, reported that, despite the contract’s signature, there was a prevailing lack of interest and knowledge among the involved parties, illustrating strong local political opposition to contractualization.

On the other hand, Fadel et al.¹⁴14 Fadel AVK, Coelho ICMM, Zarpelon LFB, Almeida MJ. Conquistas, desafios e fragilidades de um contrato organizativo de ação pública ensino-saúde. Rev Saude Pub Paraná. 2022; 5(2):1-21. doi: 10.32811/25954482-2022v5n2.670.
https://doi.org/10.32811/25954482-2022v5... showed that, in their studied context, despite the weaknesses revealed by Coapes, equity of access and the guarantee of practice settings, as established by the contract, as well as the transparency of the process, were its main achievements.

Cardoso et al.¹⁵15 Cardoso VV, Lisboa N, Adelino BS, Marques IR, Vilas Boas IF, Xavier LRJ, et al. Integração ensino-serviço-comunidade na atenção primária à saúde: uma revisão integrativa. Comum Cien Saude. 2021; 32(3). doi: 10.51723/ccs.v32i03.963.
https://doi.org/10.51723/ccs.v32i03.963... emphasize that ESCI should be a focal point in places with Coapes and/or similar contractual agreements. They suggest the creation of a collective co-management space between educational institutions and healthcare service management, allowing everyone to collaborate in the joint planning of activities.

Despite Coapes being a component of Pneps and a key factor in strengthening ESCI to foster participatory processes in education and professional development, there remains a significant gap in the lack of dialog spaces capable of effectively promoting education within and for SUS⁶6 Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499. doi: 10.1590/Interface.190499.
https://doi.org/10.1590/Interface.190499... ^,1616 Brasil. Ministério da Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: Ministério da Saúde; 2018..

Following an extensive search for studies demonstrating strategies for monitoring, evaluation, and management of ESCI through Coapes, there was a scarcity of published research on the topic. Given the significance of ESCI and Coapes as avenues for change and strengthening SUS, there is an opportunity to develop a scientific field and produce new knowledge.

Thus, the present study aims to understand how ESCI has developed through Coapes. To achieve this, it seeks to capture the perceptions of the members of the Local Management Committee of Coapes regarding ESCI within the context of SUS in Bragança Paulista, SP.

Methodology

This case study was based on the methodology proposed by Yin¹⁷17 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015., which proved to be particularly suitable as it sought to analyze a contemporary phenomenon with limited control over the behavioral events involved.

The municipality of Bragança Paulista is the headquarters of the Bragança Health Region (RS) and, according to the 2022 Census, has a population of 176.811 inhabitants. It is the most populous municipality among those that make up the region and houses the largest number of public health facilities and educational institutions¹⁸18 Instituto Brasileiro de Geografia e Estatística. Diretoria de Pesquisas, Coordenação de População e Indicadores Sociais. Panorama Bragança Paulista – SP [Internet]. 2020 [citado 14 Out 2023]. Disponível em: https://cidades.ibge.gov.br/brasil/sp/braganca-paulista/panorama
https://cidades.ibge.gov.br/brasil/sp/br... .

Bragança Paulista was chosen as the research setting due to its use of practice scenario mapping, unique projects for strengthening ESCI, and being the coordinating municipality of the Regional Coapes established in 2016. This scenario has, in turn, included the participation of all 11 municipalities in the Bragança RS and ten educational institutions since 2019. Currently, it offers 11 undergraduate courses, two residency programs (medical and multiprofessional), and four technical vocational education courses.

The Local Management Committee of the Regional Coapes is characterized as a space for discussion, monitoring, and evaluation of contractual execution, consisting of 67 members representing municipalities, educational institutions, social control (user segment), and the EPS of the coordinating municipality.

This study employed a qualitative, descriptive, and exploratory approach, using an intentional sample¹⁹19 Richardson RJ. Pesquisa social - métodos e técnicas. 4a ed. Barueri: Grupo GEN; 2017., selected based on the choice of ten Local Management Committee members who had a direct role in the research setting. The distribution of interviewees aimed for a homogeneous sample familiar with the subject to address the needs of the study’s objectives and represent different actors and institutions. Therefore, the study included five representatives from educational institutions (managers, teachers, and students), one representative from technical education (teacher), one representative from the Residency Program (student), and three representatives from SUS (EPS, management, and social control), with a predominant presence of participants from the education sector.

After ethical approval, the researchers presented the study in a meeting of the Local Management Committee of the Regional Coapes and later made formal contact via email with potential participants. Respecting the need for social distancing imposed by the COVID-19 pandemic, interviews were conducted virtually, utilizing video conferencing tools to ensure video and audio quality and information security.

An electronic form was prepared, including access to the Informed Consent Form (ICF) and the Authorization for Image and Audio Use Form (AU), which participants were asked to agree to. The form also included items for categorizing the sample’s demographic and professional data, considering the sociodemographic and professional information of the ten interviewees.

The individual interviews were conducted using a semi-structured script, addressing specific questions related to the understanding and development of ESCI in the daily activities of SUS and educational institutions based on the experience of Coapes. This approach allowed the interviewees to freely express their opinions on topics that emerged in connection with the main subject²⁰20 Gerhardt TE, Silveira DT. Métodos de pesquisa. Porto Alegre: Editora UFRGS; 2009.. The average duration of the interviews was 25 minutes, totaling 253 minutes of recorded material.

As a reflective tool, a field diary was used to record perceptions and considerations regarding interactions with the interviewees and to establish boundaries and risks related to the method and one of the researchers professional relationship with the study area²⁰20 Gerhardt TE, Silveira DT. Métodos de pesquisa. Porto Alegre: Editora UFRGS; 2009..

To ensure the confidentiality of participants’ identities, transcriptions were identified by alphanumeric extensions, with “E” (Interviewee), followed by ascending cardinal numbers in the order of the interviews (E1...E10).

The content analysis of the interviews began with pre-analysis, organizing and floating reading of the produced material according to the criteria of exhaustiveness, representativeness, homogeneity, relevance, and exclusivity, following the qualitative approach²¹21 Bardin L. Análise de conteúdo. Tradução de Luís Antero Reto e Augusto Pinheiro. São Paulo: Edições 70; 2016..

Subsequently, the materials were explored to recognize singularities, define guiding axes, context units, and registration units, based on categorization, which is considered the central element of content analysis. Categorization involved the classification of elements that group together based on defined criteria and form a set of meanings²¹21 Bardin L. Análise de conteúdo. Tradução de Luís Antero Reto e Augusto Pinheiro. São Paulo: Edições 70; 2016.^,2222 Franco MLPB. Análise de conteúdo. 3a ed. Brasília: Líber Livro; 2008. .

The research followed the guidelines of Resolution n. 466/2012 of the National Health Council and was approved by the Ethics Committee under CAAE 15095219.1.0000.5505, Opinion No. 5.143.303 dated December 3, 2021.

Results

Following the sample categorization, the sociodemographic and professional profile of the ten participants was outlined as follows: 80% were female; 70% were of white ethnicity and aged between 40 and 59 years; 70% held a postgraduate degree, with 40% having completed a Lato sensu (MBA/Specialization) and 30% a Stricto sensu (Master’s/Doctoral) program.

Regarding their field of work, 50% worked in Educational Institutions affiliated with Coapes, 30% in the SUS, and 20% in both. In terms of their area of expertise, 40% were educational institution managers, 40% were teachers in training practices, 20% were professionals in the EPS, 20% were students in the healthcare field, 10% were SUS managers, and 10% were health councilors (user segment).

Regarding their involvement in ESCI, 60% had been involved for a period ranging from 2 to 4 years, and 20% for 11 years or more; 80% had some form of training in the management area, predominantly with specialization/MBA degrees.

To adhere to Bardin’s²¹21 Bardin L. Análise de conteúdo. Tradução de Luís Antero Reto e Augusto Pinheiro. São Paulo: Edições 70; 2016. methodology for content analysis, an initial pre-analysis of the interview material was conducted. This included the review and literal transcription of the recordings, as well as organization and floating reading. From this process, three categories and their respective subcategories emerged.

The first category, “Integration of Teaching-Service-Community in the Context of Health Education and Work”, featured three subcategories: Different Perceptions of Integration of Teaching-Service-Community and Its Importance for Education in/for the SUS, Indissociability between Teaching, Research, and Extension, and Challenges in Creating Spaces for Preceptorship and Preceptor Training.

Discussions about ESCI expanded and strengthened with the Coapes, as evidenced by the subcategory Different Perceptions of Integration of Teaching-Service-Community and Its Importance for Education in/for the SUS:

Similar results have been observed in current literature, emphasizing the need to reintegrate ESCI into academic life as a guiding principle for changes in health education through permanent spaces for reflection and dialogue. This demonstrates that through collective reflection and intervention, it is possible to teach and learn in the context of healthcare services²³23 De-Carli AD, Silva ADM, Zafalon EJ, Mitre SM, Pereira PZ, Bomfim RA, et al. Integração ensino-serviço-comunidade, metodologias ativas e Sistema Único de Saúde: percepções de estudantes de odontologia. Cad Saude Colet. 2019; 27(4):476-83. doi: 10.1590/1414-462X201900040452.
https://doi.org/10.1590/1414-462X2019000... ^,2424 Matos TM. A integração ensino-serviço no enfrentamento à Covid-19 em João Pessoa - PB [dissertação]. Natal: Universidade Federal do Rio Grande do Norte; 2021..

The second subcategory, Indissociability between Teaching, Research, and Extension as a fundamental axis of the Brazilian university, was identified in the discussions as challenges to achieving this closeness and the importance of opportunities that enable such connection:

This indicates a thoughtful approach to strengthening the relationship between teaching, research, and extension, potentiated with the genesis of Coapes. However, attention should be paid to issues highlighted by De-Paula et al.²⁵25 De Paula DPS, Gonçalves MD, Rodrigues MGJ, Pereira RS, Fonseca JRO, Machado AS, et al. Integração do ensino, pesquisa e extensão universitária na formação acadêmica: percepção do discente de enfermagem. Rev Eletr Acervo Saude. 2019; 33:e549. doi: 10.25248/reas.e549.2019.
https://doi.org/10.25248/reas.e549.2019... regarding the integration of extension into teaching and research, with a focus on involvement in different territories, promoting institutional interest in engaging the academic community and providing quality services to society.

Recognizing this need, it becomes essential to implement educational strategies aimed at developing teaching skills, so that educators can promote professional education aligned with the SUS while minimizing conflicts in the daily healthcare service environment.

The third subcategory, Challenges in Creating Spaces for Preceptorship and Preceptor Training, demonstrates that while such spaces have been encouraged in the context of the Regional Coapes, challenges still exist that need future investment, as observed in the reports about the Preceptorship and Supervision Program in Internship and Residency Activities in the municipality. Despite being established in 2019, it still raises expectations and concerns among the involved stakeholders:

This circumstance should not be considered an anomaly, as paradigm shifts do not occur rapidly; they require continuous effort and resilience. For example, Mendes et al.²⁶26 Mendes TMC, Ferreira TLS, Carvalho YM, Silva LG, Souza CMCL, Andrade FB. Contribuições e desafios da integração ensino-serviço-comunidade. Texto Contexto Enferm. 2020; 29:e20180333. doi: 10.1590/1980-265X-TCE-2018-0333.
https://doi.org/10.1590/1980-265X-TCE-20... refer to the integration of the university with healthcare services, noting a range of challenges to be overcome, especially those related to the training process and the relationship of the social actors involved (educators, students, preceptors, and the community itself).

In the second category, “Organizational Public Action Teaching-Health Contract” as a guiding element for strengthening the integration of teaching-service-community, three subcategories also emerged: Communication as a Facilitator of Integration of Teaching-Service-Community and the Organizational Public Action Teaching-Health Contract, Challenges in Implementing the Integration of Teaching-Service-Community and the Organizational Public Action Teaching-Health Contract, and Strategies for Monitoring, Evaluation, and Management of Integration of Teaching-Service-Community.

As evident in the subcategory Communication as a Facilitator of Integration of Teaching-Service-Community and the Organizational Public Action Teaching-Health Contract, the study area has made significant progress in this regard:

Cardoso et al.¹⁵15 Cardoso VV, Lisboa N, Adelino BS, Marques IR, Vilas Boas IF, Xavier LRJ, et al. Integração ensino-serviço-comunidade na atenção primária à saúde: uma revisão integrativa. Comum Cien Saude. 2021; 32(3). doi: 10.51723/ccs.v32i03.963.
https://doi.org/10.51723/ccs.v32i03.963... believe that planning and communication are essential factors in avoiding conflicts that hinder the realization of ESCI. Therefore, actions to reduce student turnover, better distribution of students in practice settings, promotion of stronger bonds, as well as learning and collaboration in the workplace, must be consistently reinforced.

The subcategory Challenges in Implementing the Integration of Teaching-Service-Community and the Organizational Public Action Teaching-Health Contract highlights issues related to the physical structure of healthcare services. Inadequate infrastructure, lack of materials, and equipment for care were mentioned as recurring problems. However, the challenges extend beyond structural issues:

It is considered that unpreparedness regarding pedagogical and professional practices on the part of healthcare teams, as well as the resistance of the teaching staff to modify their teaching methods and engage in healthcare services, demonstrate different goals between the educational institution and healthcare provider, posing a potential challenge to the realization of ESCI⁸8 Zarpelon LFB, Terencio ML, Batista NA. Integração ensino-serviço no contexto das escolas médicas brasileiras: revisão integrativa. Cienc Saude Colet. 2018; 23(12):4241-8. doi: 10.1590/1413-812320182312.32132016.
https://doi.org/10.1590/1413-81232018231... ^,1515 Cardoso VV, Lisboa N, Adelino BS, Marques IR, Vilas Boas IF, Xavier LRJ, et al. Integração ensino-serviço-comunidade na atenção primária à saúde: uma revisão integrativa. Comum Cien Saude. 2021; 32(3). doi: 10.51723/ccs.v32i03.963.
https://doi.org/10.51723/ccs.v32i03.963... .

The subcategory Strategies for Monitoring, Evaluation, and Management of Integration of Teaching-Service-Community is among the responsibilities assigned to the Local Management Committee of Coapes and emerged as a subcategory¹⁰10 Brasil. Ministério da Educação, Ministério da Saúde. Portaria Interministerial nº 1.127, de 04 de agosto de 2015. Institui as diretrizes para a celebração dos Contratos Organizativos de Ação Pública Ensino-Saúde (Coapes), para o fortalecimento da integração entre ensino, serviços e comunidade no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 5 Ago 2015..

The document analysis of the records of eight meetings held between 2019 and 2022 (with the exception of 2020 when actions were suspended due to the COVID-19 pandemic) was conducted based on documents provided by the Local Management Committee of the Regional Coapes. However, no evidence of monitoring and evaluation indicators was found in the documents. Nevertheless, nuances of how this activity has been structured were identified in the statements of the Local Management Committee members:

Among the mechanisms mentioned, it is observed that the regulation of practice settings is established and that actions are defined through mapping, planning meetings, especially for internships. Monitoring has used satisfaction surveys as the primary mechanism to understand the perceptions of those involved and guide future activities.

Considering the clear need for a collective co-management space to organize ESCI and strengthen Coapes, it is essential that, among the aspirations for expansion and improvement identified, the strengthening of the Local Management Committee should include proposals to advance in monitoring and evaluating the actions developed, to create strategies that reduce contradictions, strengthen EPS, and maintain the commitment to mutual and collaborative responsibilities, respecting and valuing the principles of the SUS¹⁵15 Cardoso VV, Lisboa N, Adelino BS, Marques IR, Vilas Boas IF, Xavier LRJ, et al. Integração ensino-serviço-comunidade na atenção primária à saúde: uma revisão integrativa. Comum Cien Saude. 2021; 32(3). doi: 10.51723/ccs.v32i03.963.
https://doi.org/10.51723/ccs.v32i03.963... .

From the last category, “Importance of the Community for Education in/for the SUS”, two subcategories emerged: ESCI as a Right and Duty of the Community and Community Participation in Decision-Making Processes of the Brazilian National Health System.

The subcategory ESCI as a Right and Duty of the Community is based on the discourse of Pereira et al.²⁷27 Pereira ALP, Zilbovicius C, Carnut L, Souza Neto AC. A integração ensino-serviço-gestão-comunidade na percepção de preceptores de graduandos na Atenção Primária à Saúde. Physis. 2022; 32(3):e320305. doi: 10.1590/S0103-73312022320305.
https://doi.org/10.1590/S0103-7331202232... , emphasizing that popular participation, as a fundamental and democratic characteristic in SUS decisions, goes far beyond the role of being a mere evaluator of healthcare satisfaction. This reiterates that society should be involved in discussions about decisions related to the formulation, execution, and evaluation of national and local health policies, considering, in this context, education in/for the SUS.

The following content demonstrates that ESCI is part of the discussions of the Municipal Health Council and that the community’s role in understanding that ESCI is both a right and duty of citizenship, and that this participation is not always respected and valued by education and healthcare:

The results presented suggest that the local reality aligns with the aspirations presented by Fadel et al.¹⁴14 Fadel AVK, Coelho ICMM, Zarpelon LFB, Almeida MJ. Conquistas, desafios e fragilidades de um contrato organizativo de ação pública ensino-saúde. Rev Saude Pub Paraná. 2022; 5(2):1-21. doi: 10.32811/25954482-2022v5n2.670.
https://doi.org/10.32811/25954482-2022v5... , where the concrete operationalization of ESCI is necessary to promote dialogic spaces between education, SUS, and the community—establishing a horizontal relationship, collaborative work processes, common interests, and alignment of needs.

While the subcategory Community Participation in Decision-Making Processes of the SUS emerged, there is still a gap in the community’s understanding that ESCI is a right and duty of citizenship and that this participation is not always respected and valued by the education and healthcare sectors:

Silva et al.²⁸28 Silva HGN, Oliveira BC, Santos LES, Claro ML. O papel social da universidade mediante integração ensino-serviço-comunidade no Brasil: revisão sistemática e metassíntese. Linhas Crit. 2020; 26:e31262. doi: 10.26512/lc.v26.2020.31262.
https://doi.org/10.26512/lc.v26.2020.312... emphasize the importance of community participation in ESCI, stating that not giving the community a voice in science is a disservice to the discourse, action, and reaction of SUS and the social and educational role of the university as a democratic, progressive, and liberating institution. Thus, the active involvement of healthcare service users should be viewed as a guiding principle for policies and social engagement, changing paradigms in the training of healthcare professionals to be more sensitive and capable of critical and reflective work in response to user needs.

Connecting literature with local reality, it becomes evident that the constant involvement of the community in ESCI and Coapes coordination spaces should always be a priority, as it allows for participation in official decision-making spaces, including the possibility of developing in students the ability to actively listen to SUS users.

Final Considerations

The study retrieved the understanding that professional training in the healthcare field should occur through the construction of pedagogical projects aligned with the principles and assumptions of the SUS. This recognition emphasizes the need for dialogical relationships between decision-making instances in educational and healthcare institutions, in favor of effective EPS and the operationalization of Community-Based Education as a means to sustain the lifelong learning process.

The Coapes is highlighted as an instrument to bring institutional relations closer by promoting the participation and commitment of the parties involved in realizing ESCI. However, over recent years, there has been minimal scientific evidence regarding its contributions in directing training for the SUS.

The research shows that, like in most parts of the country, the realization of ESCI has not yet been fully consolidated in the studied scenario. Nevertheless, significant progress and the relevance of Coapes in this process have been noted.

The perceptions of the Local Management Committee representatives regarding how Coapes has been established suggest that the opportunity for dialogical relationships, combined with new projects and attitudes, is the most notable achievement. The regulation of student access to practice settings, unique teaching-health projects, and the shared responsibility of education when engaging with the SUS are concrete examples of the progress observed. Nevertheless, there is still much to be achieved.

Physical infrastructure, pedagogical practices, and the misalignment between education and healthcare have been identified as ongoing challenges. The absence of community involvement through social control representation in official academic decision-making spaces and the resistance of social actors, particularly in relation to the establishment of preceptorship and preceptor training spaces, demonstrate limitations to the different roles and responsibilities, highlighting the challenges to be overcome and requiring future investments.

Understanding how the monitoring and evaluation of ESCI has been structured reveals that the mapping of practice settings arises from planning meetings, technical visits, feedback, and the assessment of the perceptions and satisfaction of the social actors involved. Above all, creating mechanisms that allow the identification of progress, setbacks, and the use of quantitative and qualitative indicators is essential for a clearer understanding of the existing scenario and as a tool to guide new decisions and necessary adjustments.

The research provided a better understanding of the development of ESCI and Coapes in the municipality of Bragança Paulista, SP. Thus, it was concluded that the sustainability and achievements of the contract result from strategies such as approach, institutional dialogue, equal value, and transparency, resulting from technical discussions, process understanding, format selection, awareness, and engagement of the actors. These aspects can be explored in other territories and in future research. However, the study was limited to relying solely on the perception of the Local Management Committee of Coapes, preventing a comprehensive understanding of the topic in the chosen scenario. For future research, the challenge is to propose measurement and verification methods using evaluation techniques to demonstrate the analytical-explanatory nature of the integration between education, service, and the community, as well os its value in training for the SUS.

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